Remind me about this plane crash…

Here’s what happened: 

• In August, 2020, an Air India Express plane overshot the runway in Kozhikode, Kerala, and broke into two—killing 21 people, including both pilots. 
• The two-year-old Boeing 737-800 flew in from Dubai on Friday at 7:40 pm in the midst of torrential rain. 
• It was a repatriation flight, bringing back 174 adult Indians, 10 infants, two pilots and four cabin crew. 
• Many of them were working class Indians who had lost their Middle East jobs to the pandemic—and were waiting for months to return home. 
• The pilot was 56-year-old Deepak Sathe—a highly experienced former Wing Commander in the Indian Air Force—who had successfully landed the plane 27 times at Kozhikode. The co-pilot was 32-year-old Akhilesh Kumar.

Point to note: At the time of the crash, there were a number of key complicating factors. The pilots were attempting to land in the middle of a thunderstorm—with strong winds and poor visibility. And they were landing in what is known as a tabletop airport—i.e. it is built on top of a hill with one or both ends of the runway ending in a steep drop. There are seven such airports in the country: Lengpui (Mizoram), Shimla and Kullu (Himachal Pradesh), Pakyong (Sikkim), Kozhikode and Kannur (both Kerala) and Mangalore (Karnataka)—where the previous such tragedy occurred. See what the airport runway looks like below:

So what does the report say…

Let’s start with human error. It is now clear that the pilot in command Sathe made a number of bad decisions. 

One: After a first failed landing, he made a second attempt on runway 10—with strong tailwinds of 11 knots (20 km/hour), which pushed the plane forward, and over the edge. Here’s what the report found:

"Before the approach for runway 10 as well, the Pilot in Command did not carry out adequate briefing for landing with tailwinds, in rain and poor visibility. The mandatory calculation of landing distances was omitted.”

And this when at least one of the windshield wipers wasn’t functioning.

Two: Standard Operating Procedures called for diverting the plane to the nearest airport—in this case Tiruchirappally in Tamil Nadu, 45 minutes from the Kozhikode airport:

“The Pilot in Command took a decision not to divert after the [first] 'missed approach' on runway 28 even though there were alternate airfields available in close proximity and there was enough fuel on board. Subsequently, without any risk assessment, the Pilot in Command continued for a second approach into Kozhikode.”

Three: The co-pilot urged Sathe to ‘Go Around’ after the first failed landing—but was ignored:

"After making two unassertive attempts to attract the Pilot in Command's attention towards the unstabilized approach, using non-standard vocabulary, he asked the Pilot in Command to 'Go Around' just before touchdown. In spite of knowing full well that the approach was unstabilized and the Pilot in Command was not responding, the First Officer did not take over the controls as per the company Standard Operating Procedures and initiate a 'Go Around'.”

FYI: A 'Go Around' is when pilots decide to abort a landing before or after touching down if they feel that it is not safe.

Four: The pilot may have made errors due to underlying medical conditions:

“The pilot in command was taking multiple un-prescribed anti-diabetic drugs that could have probably caused subtle cognitive deficits due to mild hypoglycaemia, which probably contributed to errors in complex decision-making.”

And what about those ‘systemic failures’?

Here’s what the report flagged:

One: The lack of onboard equipment to help pilots calculate accurate landing data in adverse weather conditions. Also: The tower meteorological officer (TMO), was not present at the airport at the time of the accident, despite the fact that the airfield was under two concurrent weather warnings. In such situations, a TMO has to be present to update and inform authorities of fast changing weather patterns.

Two: The report also flagged a “prevailing safety culture that gives rise to errors, mistakes and violation of routine tasks performed by people operating within the system.” And the lack of effective training. This also accounts for why the co-pilot did not intervene to prevent the tragedy. The report attributes this to “a steep authority gradient in the cockpit”—i.e. the power differential between the pilots that prevented the first officer from taking over controls.

Three: Air India is clearly understaffed—which made the pilot anxious to land in Kozhikode. He was slated to fly another flight the next morning—since there were not sufficient pilots assigned to the Kozhikode airport. There was only 1 Captain against 26 First Officers posted at Kozhikode.

Not flagged by the report: The fact that the Kozhikode airport itself is unsafe in bad weather conditions. Two safety measures were strongly recommended in the past—and both have not been implemented. 

One: is something called an EMAS or Engineered Materials Arrestor/Arresting System—made of lightweight and crushable cellular cement/concrete. It is basically an ‘arresting bed’ built at the end of a runway to stop a plane in its tracks. An investigation into the Mangalore crash recommended their implementation at all tabletop airports. In a 2011 letter, a senior government advisor specifically warned: 

“All flights landing at the runway at Kozhikode ‘in tailwind condition in rain are endangering the lives of all on board… It is a dangerous situation, especially in wet conditions.’”

But the advice was rejected by Kozhikode’s airport director.

Two: Extending the length of the runways. Back in 2017, the Airports Authority of India made plans to extend Kozhikode’s 2750-metre runway by 800 metres. The plan initially required an additional 800 acres—which was reduced to 100 acres. But it was shelved due to resistance from local residents who refused to give up their land.

Three: In the absence of such measures, authorities could also have restricted the airport to only narrow-body planes and banned landings on runway 10 during the monsoons.

The bottomline: We’re seriously reconsidering taking a flight during monsoon season ever again.

Reading list

NDTV and Economic Times have the most details on the investigation. The Hindu offers a guide to tabletop airports—and the aviation rules that applied to both pilots and airports. Also read: an India Today cover story from 2012 (after the Mangalore tragedy) on how profit trumps safety at Indian airports. Not much has changed since. And we did a detailed explainer on the crash back in August 2020.